Role of Indocyanine Green in Fluorescence Imaging with Near-Infrared Light to Identify Sentinel Lymph Nodes, Lymphatic Vessels and Pathways Prior to Surgery - A Critical Evaluation of Options

Andreas Hackethal, Markus Hirschburger, Sven Oliver Eicker, Thomas Mücke, Christoph Lindner, Olaf Buchweitz, Andreas Hackethal, Markus Hirschburger, Sven Oliver Eicker, Thomas Mücke, Christoph Lindner, Olaf Buchweitz

Abstract

Modern surgical strategies aim to reduce trauma by using functional imaging to improve surgical outcomes. This reviews considers and evaluates the importance of the fluorescent dye indocyanine green (ICG) to visualize lymph nodes, lymphatic pathways and vessels and tissue borders in an interdisciplinary setting. The work is based on a selective search of the literature in PubMed, Scopus, and Google Scholar and the authors' own clinical experience. Because of its simple, radiation-free and uncomplicated application, ICG has become an important clinical indicator in recent years. In oncologic surgery ICG is used extensively to identify sentinel lymph nodes with promising results. In some studies, the detection rates with ICG have been better than the rates obtained with established procedures. When ICG is used for visualization and the quantification of tissue perfusion, it can lead to fewer cases of anastomotic insufficiency or transplant necrosis. The use of ICG for the imaging of organ borders, flap plasty borders and postoperative vascularization has also been scientifically evaluated. Combining the easily applied ICG dye with technical options for intraoperative and interventional visualization has the potential to create new functional imaging procedures which, in future, could expand or even replace existing established surgical techniques, particularly the techniques used for sentinel lymph node and anastomosis imaging.

Keywords: ICG; indocyanine green; sentinel.

Conflict of interest statement

Conflict of Interest/Interessenkonflikt AH: Perform live surgery and participation in expert meetings for Olympus. AH: Durchführung von Live-Operationen, Teilnahme an Expertenmeetings für Olympus.

Figures

Fig. 1
Fig. 1
Number of “Indocyanine Green” publications in PubMed over various periods.
Fig. 2
Fig. 2
Intraoperative screen shot of fluorescence ICG sentinel lymph node biopsy in the right pelvis.a HD white light image of the site,b near-infrared image at the same site with pale-stained ICG-containing tissue.c Combined HD image with fluorescent green color.d Quantitative ICG image of fluorescence-containing tissue indicating the presence of a lymph node in the obturator fossa.
Fig. 3
Fig. 3
Applications in neurosurgery.ashows reduced flow at the cortical surface with circulatory insufficiency (white arrow). At maximum flow this is particularly visible in the color-coded image (b, blue areas).cshows how ROIs (regions of interest) can be measured. Physicians can select an artery (green), vein (blue) or cortex (red). Areas of infarction or tumor areas can be highlighted.dshows the quantitative images for these regions.eImage of the spinal cord of a patient with a spinal arteriovenous fistula. Under white light illumination (black arrow), the suspicious vessel fills too quickly during ICG video angiography (f, white arrow), allowing it to be identified as a fistula vessel.
Fig. 4
Fig. 4
Color-coded imaging (FLOW ® 800) of the afferent (yellow-orange) artery and the efferent vein (green) of a microvascular, latissimus dorsi tissue flap after successful anastomosis.
Abb. 1
Abb. 1
Publikationsanzahl „Indocyanine Green“ in PubMed in jeweiligen Zeiträumen.
Abb. 2
Abb. 2
Intraoperativer Screenshot einer ICG-Sentinelbiopsie im Bereich des rechten Beckens.azeigt das HD-Weißlichtbild des Situs,bdas Nah-Infrarotbild mit weißlich angefärbtem ICG-haltigen Gewebe.czeigt das Kombinationsbild in HD mit Fluoreszenzgrün-Färbung.dzeigt die quantitative ICG-Darstellung des fluoreszenzhaltigen Gewebes, als Ausdruck eines Lymphknotens im Bereich der Fossa obturatoria.
Abb. 3
Abb. 3
Anwendungsbeispiele aus der Neurochirurgie. Inazeigt sich auf der kortikalen Oberfläche eine Flussverzögerung mit Minderdurchblutung (weißer Pfeil). Im maximalen Fluss zeigt sich dies besonders im farbkodierten Bild (b, blau dargestellte Areale). Exemplarisch ist incdie Möglichkeit der Messung von ROIs (Region of Interest) dargestellt. Je eine Arterie (grün), Vene (blau) und Kortex (rot) können ausgewählt werden. Ebenso könnten Infarktareale oder Tumorareale markiert werden. Indsind diese Regionen entsprechend quantitativ dargestellt.eist die Aufsicht auf das Rückenmark bei einem Patienten mit spinaler arteriovenöser Fistel. Das suspekte Gefäß in der Weißlicht-Aufsicht (schwarzer Pfeil) füllt sich in der ICG-Videoangiografie entsprechend zu früh (f, weißer Pfeil) und kann als Fistelgefäß identifiziert werden.
Abb. 4
Abb. 4
Farbkodierte Darstellung (FLOW ® 800) der zuführenden (gelb-orange) Arterie und der abführenden Vene (grün) eines mikrovaskulären Latissimus-dorsi-Gewebetransplantats nach erfolgreicher Anastomosierung.

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